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New HIV diagnoses among adults aged 50 years or older in 31 European countries, 2004–15: an analysis of surveillance data Lara Tavoschi, Joana Gomes Dias, Anastasia Pharris, on behalf of the EU/EEA HIV Surveillance Network*
Summary
Background The HIV burden is increasing in older adults in the European Union (EU) and European Economic Area (EEA). We investigated factors associated with HIV diagnosis in older adults in the 31 EU/EEA countries during a 12 year period. Methods In this analysis of surveillance data, we compared data from older people (aged ≥50 years) with those from younger people (aged 15–49 years). We extracted new HIV diagnoses reported to the European Surveillance System between Jan 1, 2004, and Dec 31, 2015, and stratified them by age, sex, migration status, transmission route, and CD4 cell count. We defined late diagnosis as CD4 count of less than 350 cells per µL at diagnosis and diagnosis with advanced HIV disease as less than 200 cells per µL. We compared the two age groups with the χ² test for difference, and used linear regression analysis to assess temporal trends. Findings During the study period 54 102 new HIV diagnoses were reported in older adults. The average notification rate of new diagnoses was 2·6 per 100 000 population across the whole 12 year period, which significantly increased over time (annual average change [AAC] 2·1%, 95% CI 1·1–3·1; p=0·0009). Notification rates for new HIV diagnoses in older adults increased significantly in 16 countries in 2004–15, clustering in central and eastern EU/EEA countries. In 2015, compared with younger adults, older individuals were more likely to originate from the reporting country, to have acquired HIV via heterosexual contact, and to present late (p<0·0001 for all comparisons). HIV diagnoses increased significantly over time among older men (AAC 2·2%, 95% CI 1·2–3·3; p=0·0006), women (1·3%, 0·2–2·4; p=0·025), men who have sex with men (5·8%, 4·3–7·5; p<0·0001), and injecting drug users (7·4%, 4·8–10·2; p<0·0001). Interpretation Our findings suggest that there is a compelling need to deliver more targeted testing interventions for older adults and the general adult population, such as by increasing awareness among health-care workers and expanding opportunities for provider-initiated and indicator-condition-guided testing programmes.
Lancet HIV 2017 Published Online September 26, 2017 http://dx.doi.org/10.1016/ S2352-3018(17)30155-8 This online publication has been corrected. The corrected version first appeared at thelancet.com/hiv on September 27, 2017. See Online/Comment http://dx.doi.org/10.1016/ S2352-3018(17)30151-0 *Members listed at the end of the paper European Centre for Disease Prevention and Control, Solna, Sweden (L Tavoschi PhD, J Gomes Dias MSc, A Pharris PhD) Correspondence to: Dr Lara Tavoschi, European Centre for Disease Prevention and Control, Tomtebodavägen 11A, 171 65 Solna, Sweden lara.tavoschi@ecdc.europa.eu
Funding European Centre for Disease Prevention and Control.
Introduction The global population is ageing as a combined result of improvements in living standards, decreasing mortality, and declining fertility.1 Data from high-income countries, such as the 31 member states of the European Economic Area (EEA, which consists of the 28 countries of the European Union [EU] plus Iceland, Liechtenstein, and Norway), show a steady increase in life expectancy at age 60 years.2 Health and ageing are high on the global agenda in view of the growing burden of disease among adults aged 50 years or older, the corresponding need for healthcare systems to adapt to evolving demands, and the call to invest in healthy ageing.3 In 2013, UNAIDS estimated that 4·2 million people aged 50 years or older were living with HIV worldwide. The prevalence of HIV in this segment of the population has steadily increased over the past couple of decades in all WHO regions, particularly in central and western Europe, the USA, and Canada.2,4 This increase has been attributed to two distinct factors: the rise in life expectancy among people living with HIV on antiretroviral therapy
(ART), and the rise, in some settings, in the number of people seroconverting at older ages.2,4–6 An increasing trend of new HIV diagnoses among adults aged 50 years or older across the WHO European region5 and in specific EEA countries6,7 has been noted. However, no in-depth analysis has been done of the population of older adults newly diagnosed with HIV in the EU/EEA. Estimation of the incidence of HIV is challenging, because infection might have occurred several years before symptoms arise or diagnosis is made. A proxy is provided by surveillance of new diagnoses reported over time. An estimate of about 30 000 new infections occur annually across all age groups in the EU/EEA, with substantial variability in notification rates across countries.8,9 Studies suggest that older adults infected with HIV are more likely to present late6,7,10 and are at increased risk of short-term mortality6,11 than are younger adults. Older adults living with HIV and health professionals caring for them face unique challenges, first and foremost that of increasing coverage and uptake of testing to promote early diagnosis and reduce stigma.12
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Research in context Evidence before this study We did a literature review during the scoping phase of the study to assess the available evidence on new diagnoses of HIV among older adults in the European Union (EU) and European Economic Area (EEA) and other high-income countries. In March, 2016, we did a combined search of PubMed and Embase using a strategy developed to include concepts of HIV infection and disease, older adults, testing, and attitudes towards testing. We used controlled vocabulary available in the bibliographic databases (ie, MeSH and Emtree terms) and natural vocabulary in multiple field search combinations to represent the concepts in the search strategies. We searched for articles published in any language, and ran monthly updates of our search until June 30, 2017. We identified only a few studies (most were national studies) that focused on HIV infection and disease in older adults. One article focused on new HIV diagnoses among older adults in 2003–07 in the broader WHO European region. Finally, in 2013, UNAIDS published a special report on the global HIV epidemic among older adults.
Aged 15–49 years (n=24 343)
Aged ≥50 years (n=5076)
% difference
p value
18 715 (76·9%)
3937 (77·6%)
+0·7%
··
5591 (23·0%)
1131 (22·3%)
–0·7%
··
Sex Male Female Unknown
0·57
37 (0·2%)
8 (0·2%)
0
Transmission route* Heterosexual sex
·· <0·0001
7495 (30·8%)
2153 (42·4%)
+11·6%
··
Sex between men
10 989 (45·1%)
1540 (30·3%)
–14·85%
··
Injecting drug use
1108 (4·6%)
132 (2·6%)
–2·0%
··
Unknown or other
4751 (19·5%)
1251 (24·6%)
+5·1%
··
CD4 cell count (per µL)* Median (95% CI)
<0·0001 394 (388–400)
240 (230–255)
··
·· ··
<200
3704 (15·2%)
1390 (27·4%)
+12·2%
≥200 to <350
2790 (11·5%)
606 (11·9%)
+0·4%
··
≥350 to <500
3121 (12·8%)
455 (9·0%)
–3·8%
··
≥500
5333 (21·9%)
704 (13·9%)
–8·0%
··
Unknown
9395 (38·6%)
1921 (37·8%)
–0·8%
··
13 106 (53·8%)
3235 (63·7%)
+9·9%
··
Born in EU or EAA
1529 (6·3%)
177 (3·5%)
–2·8%
··
Not born in EU or EAA
6241 (25·6%)
874 (17·2%)
–8·4%
··
Unknown country of birth or region of origin
3467 (14·2%)
790 (15·6%)
+1·4%
··
Migration history* Native to reporting country
<0·0001
Data are n (%) unless otherwise specified. EU=European Union. EEA=European Economic Area. *Significance was computed after excluding data in the “unknown” categories.
Table: Characteristics of new, reported HIV diagnoses in people aged 15–49 years and those aged 50 years or older in EU/EEA countries, 2015
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Added value of this study Our study provides the first comprehensive overview of the HIV epidemic and its burden in older adults in EU/EEA countries. We analysed data reported to the European Surveillance System from Jan 1, 2004, to Dec 1, 2015, to identify trends and epidemic dynamics. Our comparison of sociodemographic characteristics of younger and older adults with newly diagnosed HIV could help to identify distinctive features of older adults that could contribute to the design of more effective prevention interventions. Implications of all the available evidence Our study confirms findings from some countries of an increasing trend in new diagnoses among older adults in EU/EEA countries. We have shown clear geographical patterns across the region. Our findings, alongside those from previous studies, show that older adults in the EU/EEA are a group at potential risk for HIV and that older individuals are likely to be diagnosed late across the region. Taken together, the existing evidence points towards the compelling need to consider older adults as a relevant target for HIV prevention programmes.
We aimed to describe factors associated with HIV infection and diagnosis among adults aged 50 years or older in EU/EEA countries by analysing new diagnoses reported between 2004 and 2015, to support policy decisions and the design of effective interventions for this age group.
Methods
Study population and data sources In this observational analysis of suveillance data, we defined the study population as all individuals aged 15 years or older who were newly diagnosed with HIV between Jan 1, 2004, and Dec 31, 2015, and who reported as part of routine annual surveillance by any of the 31 EU/ EEA member states to the European Surveillance System, hosted at the European Centre for Disease Prevention and Control. Case-level anonymised data are reported for each new HIV diagnosis, including date of diagnosis, age, sex, transmission mode, country of birth, country of diagnosis, CD4 cell count at diagnosis, comorbidities, laboratory test results, and disease stage.9 Although completeness of reporting for age and sex is very high (>99% during the study period), data for country of birth and migration status are somewhat less complete (86–90% during the study period). Only 23 of 31 countries report data for CD4 cell count at diagnosis, with a completeness of 68·5% for their reported cases during the study period. In accordance with previously published studies,4,6,7,13 we used 50 years of age as the cutoff to define older participants. The primary study population was individuals aged 50 years or older at HIV diagnosis, and
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the comparator group was individuals aged 15–49 years at diagnosis. We defined late diagnosis as CD4 counts less than 350 cells per µL at diagnosis, and diagnosis with advanced HIV disease as counts of less than 200 cells per µL at diagnosis.14 We defined migrant status as follows: native (born in the reporting country), EU/ EEA-born (born in an EU or EEA country different from the reporting country), or non-EU/EEA-born. We derived population estimates up to 2015 from Eurostat for all EU/EEA countries. We adjusted the population data for Spain and Italy according to the extent of subnational coverage for years when surveillance data reported to the European Surveillance System did not cover all regions, assuming uniform coverage across all age groups.
Statistical analysis We analysed the study population who received a new, reported HIV diagnosis in 2015 by sex, transmission mode, migrant status, and CD4 cell count at diagnosis. We compared the two age groups with the χ² test for difference. We assessed temporal trends by estimating the percentage change in the annual notification rate of new HIV diagnoses with 95% CIs, overall, by age group, and by country, and did linear regression
analysis of the log of the notification rate. We assessed trends in transmission mode by examining the log of the number of cases because of the absence of denominators. We defined statistical significance as a p value of less than 0·05. We used STATA (version 14.0) for all statistical analyses.
Data sharing The European Surveillance System data are available by request from the European Centre for Disease Prevention and Control.
Role of the funding source The funder had no role in study design; data collection, analysis, or interpretation; or writing of the report. The corresponding author had full access to all study data and had final responsibility for the decision to submit for publication.
For Eurostat see http://ec. europa.eu/eurostat/data/ database For European Surveillance System data see https://ecdc. europa.eu/en/publications-data/ european-surveillance-systemtessy
Results Of the 29 419 new HIV diagnoses reported in 2015 in people aged 15 years or older in the EU/EEA, 5076 (17·3%) were in older people (table). The notification rate of new HIV diagnoses among older people in 2015 was 2·5 per
Notification rate per 100 000 older adults <2·00 2·01–4·00 4·01–6·00 >6·00
Luxembourg
Malta
Liechtenstein
Figure 1: New HIV diagnoses among people aged 50 years or older in the European Union and European Economic Area, 2015 Administrative boundaries according to EuroGeographics, the UN Food and Agriculture Organization, Turkstat, and the Database of Global Administrative Areas.
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Annual change in HIV notification rate by age group, 2004–15 Increasing in people aged 15–49 years and those aged ≥50 years Increasing in people aged ≥50 years Decreasing in people aged 15–49 years and those aged ≥50 years No significant changes in people 15–49 years and those aged ≥50 years
Luxembourg
Malta
Liechtenstein
Figure 2: Average annual percentage change in new HIV diagnoses in people aged 50 years or older in the European Union and European Economic Area, 2004–15* Administrative boundaries according to EuroGeographics, the UN Food and Agriculture Organization, Turkstat, and the Database of Global Administrative Areas. *Cyprus, Iceland, Lichtenstein, Luxembourg, and Slovenia were not included in the analysis because no cases were reported in 1 or more year during the reporting period in each country.
100 000 population, ranging from 0·4 per 100 000 in Slovakia to 7·5 per 100 000 in Estonia (figure 1). By contrast, the notification rate of new diagnoses among younger people in the EU/EEA was 10·4 per 100 000 in 2015, ranging from 2·9 per 100 000 in Slovakia to 38·6 per 100 000 in Estonia. New HIV diagnoses among men in 2015 predominated in both age groups, with a slightly higher male-to-female ratio among older than among younger people (3·5 vs 3·3; table). The gender-specific notification rates of new diagnoses were 1·05 per 100 000 older women and 4·3 per 100 000 older men. Country of birth was reported for 25 162 (85·5%) of newly diagnosed patients with HIV in 2015. Migration status was significantly associated with age (p<0·0001), with older people more likely to be native to the reporting country than younger people (table). CD4 cell counts were available for 18 103 (61·5%) reported cases at diagnosis. A higher proportion of older adults than of younger people were diagnosed late (table). Older people also had significantly lower median CD4 counts at diagnosis than younger adults (p<0·0001; table). 4
Among cases diagnosed in 2015, reported transmission route was significantly associated with age (p<0·0001; table), with a higher proportion of cases attributed to heterosexual transmission in older people than in younger people. Notably, the proportion of HIV cases classified as having an unknown or other route of transmission was higher in older than in younger people. Between 2004 and 2015, 312 501 new HIV diagnoses were reported in younger adults in the EU/EEA. The mean notification rate of new diagnoses was 11·4 per 100 000 population across the whole 12 year period, and we noted no significant trends over time (average annual change [AAC] –0·4%, 95% CI –1·0 to 0·2; p=0·1716). Among older adults, 54 102 cases were reported in the same period, corresponding to a mean notification rate of new diagnoses of 2·6 per 100 000 population across the whole 12 year period, which significantly increased over time (AAC 2·1%, 95% CI 1·1 to 3·1; p=0·0009). Due to aggregate or inconsistent reporting we excluded Bulgaria, Estonia, Italy, Poland, and Spain from the
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A
Male individuals
20 15
Notification rate per 100 000
10
5
All Age 15–49 years Age ≥50 years
B
Female individuals
10 8 6 Notification rate per 100 000
trend analysis by transmission mode. These countries represented 24% (88 738 of 366 603) of all HIV diagnoses, and 22% (12 092 of 54 102) of the HIV diagnoses in older adults made in the EU/EEA during the study period. Additionally, we excluded from any country-specific analyses countries reporting no cases for 1 or more years— namely, Cyprus, Iceland, Liechtenstein, Luxembourg, and Slovenia. For the period 2004–15, we noted significant increases in the notification rate of new HIV diagnoses among older adults in 16 countries (appendix): Belgium (p=0·0035), Bulgaria (p=0·020), Czech Republic (p=0·0085), Estonia (p<0·0001), Germany (p<0·0001), Greece (p=0·0091), Hungary (p=0·0035), Ireland (p=0·0049), Latvia (p=0·0004), Lithuania (p=0·0046), Malta (p=0·026), Norway (p=0·026), Poland (p=0·0006), Romania (p=0·010), Slovakia (p=0·034), and the UK (p=0·0002). A significant decrease in the notification rate of new HIV diagnoses in older adults was noted in Portugal (p=0·0015). In younger people, we identified significant increases in the notification rate of new HIV diagnosis in 12 countries: Bulgaria (p<0·0001), Croatia (p<0·0001), Czech Republic (p<0·0001), Germany (p<0·0001), Greece (p=0·0019), Hungary (p<0·0001), Latvia (p=0·019), Lithuania (p=0·012), Malta (p<0·0001), Poland (p<0·0001), Romania (p=0·0004), and Slovakia (p<0·0001). We noted significant decreases in younger adults in Austria (p=0·0036), France (p=0·0074), the Netherlands (p=0·0008), Norway (p=0·022), Portugal (p<0·0001), and the UK (p<0·0001). The notification rate of new diagnoses significantly increased in both age groups in 11 countries, and decreased significantly in both age groups in one country, Portugal (figure 2). In five countries, notification rates of new diagnoses increased significantly only among older adults (figure 2), with a corresponding significant decrease in younger people in two countries (Norway and the UK; data not shown). We found an average annual notification rate of new diagnoses among older adults of 4·4 per 100 000 men and 1·2 per 100 000 women across the whole study period. The notification rate increased significantly from 2004 to 2015 in both sexes, from 3·5 to 4·8 per 100 000 men (AAC 2·2%, 95% 1·2 to 3·3; p=0·0006), and from 1·0 to 1·2 per 100 000 women (1·3%, 0·2 to 2·4; p=0·025; figure 3). In younger people, we noted a significant increase in new diagnoses in men and boys (1·4%, 0·6 to 2·3; p=0·0032) and a significant decrease in women and girls (–4·8%, –5·2 to –4·4; p<0·0001). We observed an age-specific pattern over time for reported transmission routes (figure 4). The number of new HIV diagnoses as a result of sex between men increased over time in both age groups, but the AAC was higher in older people (5·8%, 95% CI 4·3 to 7·5; p<0·0001) than in younger people (2·3%, 95% CI 1·2 to 3·5; p=0·0008). New HIV diagnoses among individuals who acquired the infection through
4
2
2004
2005
2006
2007
2008
2009 2010 Year of diagnosis
2011
2012
2013
2014
2015
Figure 3: Annual notification rate of new HIV diagnoses per 100 000 men and boys (A) and women and girls (B) in the European Union and European Economic Area, 2004–15 The y axes are on a log scale. The dotted lines represent 95% CIs.
heterosexual sex significantly decreased among younger people (AAC –5·7%, 95% CI –6·2 to –5·1; p<0·0001), but remained stable in older people (1·1%, –0·2 to 2·5; p=0·08). New HIV diagnoses attributed to injecting drug use increased among older people (7·4%, 4·8 to 10·2; p<0·0001) but decreased among younger people (–4·5%, –7·5 to –1·4; p=0·0087).
See Online for appendix
Discussion We identified a steady increase in the notification rate of new HIV diagnoses among older adults in Europe over a 12 year period. Our cross-sectional analysis shows a distinctive pattern of sociodemographic factors associated with being an older adult newly diagnosed with HIV in the EU/EEA. Newly diagnosed older adults were mainly native to the reporting country, in line with findings from national studies.6,7,11 By contrast with trends among younger adults, we showed a significant increase in new diagnoses among older men and women. Transmission via sex between men rose in both age groups between 2004 and 2015. However,
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A
Heterosexual sex
Number of cases
10 000 5000
Age 14–49 years Age ≥50 years
B
Sex between men
Number of cases
10 000
C
Injecting drug use
Number of cases
2000
2004
2006
2008
2010 Year of diagnosis
2012
2014
2016
Figure 4: Trends in new, reported HIV diagnoses per 100 000 people transmitted by transmission route in the European Union and European Economic Area, 2004–15 The y axes are on a log scale.
we noted stable or increasing trends for transmission modes such as heterosexual contact and injecting drug use among older people, compared with significant decreases among younger people. Although the notification rate of new HIV diagnoses was lower in older people than in younger people, the country-specific burden of new diagnoses among older adults was heterogeneous, with western European and Baltic countries generally reporting the highest HIV notification rates out of all countries in the region. Our finding of increasing notification rates of new diagnoses in the EU/EEA as a whole accords with previous findings from the region and other high-income settings.2,5,15 Additionally, our analysis showed similar increases in the notification rate of new HIV diagnoses over 2004–15 in most EU/EEA countries, with significant increases more common in eastern and central parts of the EU/EEA than in other countries in the region. Although the Baltic countries have been previously characterised by high HIV notification rates in the general population, countries with historically low notification rates, such as Hungary and Poland, showed similar increasing patterns 6
across age groups.8,9 Only Norway and the UK had significant increases in new reported diagnoses in older people coupled with significant decreases in younger people. Although the observed differences in notification rates among older adults across the EU/EEA are probably the result of several factors that differ across the region, including risk-behaviour patterns, health-seeking behaviours, testing programmes and patterns, and levels of stigma,5,9,16 our findings suggest a new direction or new directions in which the epidemic is evolving. Our findings revealed a slightly increased male-tofemale ratio in the older age group compared with the younger age group, although not as pronounced as that in other published work, which suggests that diagnoses in men predominate in the older age group.6,7,17,18 In line with published evidence,11,17–19 in our analysis, transmission of HIV among older adults was mainly sexual, and acquisition of the infection as a result of heterosexual sex was more common than that as a result of sex between men. More in-depth analysis in nationallevel studies suggests some evidence of risks related to commercial sex18 and travel abroad6 among heterosexual men. Injecting drug use was a less common mode of transmission among older people than among younger people in our data, as also noted in national studies.17,18 Finally, our observation of a larger proportion of HIV cases classed as having an unknown transmission mode in the older than in the younger age group is a common finding in Europe and elsewhere.7,18,20 This pattern might be the result of underlying factors such as low perception of and misconceptions about transmission risks, stigma and subsequent under-reporting of transmission as a result of sex between men, and poor risk assessment and sexual history collection by health-care providers. Although new HIV diagnoses among men have been increasing steadily over time and across age groups, our analysis suggests a divergent pattern for women. Similar to our findings in the EU/EEA, an increasing incidence of new HIV diagnoses in older women has been reported in non-EU/EEA eastern European countries,9 the USA, and Canada.15,21 No data for the reasons behind such an increase have been published. Presenting with a late diagnosis was significantly associated with older age in our analysis and in most previously published work,6,10,11,13,18,20,22 with some exceptions.19,21 A trend analysis of a subset of EU/EEA countries23 suggested that the average CD4 count at diagnosis among older adults is increasing over time, but is still well under the 350 cells per µL threshold. CD4 counts fall more rapidly in older than in younger people, which could explain the greater proportions of the older adult population diagnosed with a CD4 cell count of less than 350 cells per µL. However, late presentation is particularly worrying among older people, because it further increases the already higher mortality in this age group compared with younger individuals.6,11,19 Various studies18,24–26 across settings and population
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groups have shown that HIV testing is uncommon among older people. Newly diagnosed older people were less likely to have been previously tested and were more likely to be diagnosed incidentally while in hospital than were younger individuals.13,20 Low self-perception of risk and misconceptions or scant knowledge about HIV and HIV transmission are frequently reported as the reasons for older adults not being tested.12,24,25 The perception of older adults as not being at risk is often shared by health-care providers and society at large, and is influenced by age-related stigma.12 Studies have challenged the stereotype of asexuality among older adults26,27 and have shown some common risk behaviours, such as low levels of condom use,26 including among older adults with several risk factors for HIV.28 Furthermore, sexual health services in the EU/EEA often target or are preferentially frequented by younger people, with an associated increased likelihood of the offer of HIV testing to those accessing such services. Evidence suggests that the most significant factor affecting testing patterns in older adults is an active offer of an HIV test by service providers.24 Such an offer could be effectively prompted by the collection of sexual history or risk assessment,25 the existence of specific guidelines (eg, universal testing),12 or active case-finding initiatives.21 However, health-care providers might be reluctant to take sexual history, assess risk, advise on sexual health, or offer HIV testing for older people.12,25 Older people are frequent users of health-care services, but HIV might be diagnosed only after several physician visits.22,27 Such missed opportunities are concerning, not only because of the associated social, individual, and health-care costs, but also in view of the accumulating evidence for effective provider-initiated testing approaches. The offer of HIV testing triggered by specific health conditions (ie, indicator-condition-guided testing) is a very effective and promising approach29 that could successfully target older adults if more broadly implemented.30 Another promising approach that could warrant scale-up is opt-out testing in primary health care or in emergency departments.21,27 The EU/EEA is a heterogeneous region in terms of not only HIV epidemic history, patterns, and drivers, but also health-care infrastructure and health-service organ isation. Therefore, implementation of testing inter ventions might vary considerably on the basis of structural factors and political, cultural, and societal dynamics. Nonetheless, the EU/EEA offers an excellent platform for exchanging experiences and best practices deriving from single-site or larger-scale interventions that could help to normalise HIV testing and promote coverage and uptake of testing among older adults. Our study has some limitations. Data for two key variables, migration status and CD4 cell counts at diagnosis, were missing for some cases. Thus, we could not include data representing about a quarter of new HIV diagnoses in the analyses for transmission mode or
migration status. We tried to minimise this omission by doing sensitivity analyses with and without cases with missing data, and found that results were unchanged (data not shown). Reporting practices and data quality differ within and between countries, and, in some settings, there is substantial lag between diagnosis and reporting of the case to the national surveillance system. Because of this reporting delay, the number of cases in more recent years, particularly 2015, is likely to increase in future years. Thus, increases in trends presented are probably underestimates and decreases are probably overestimates. We attempted a multilevel analysis for trend, but stopped it because the numbers in some strata were small. However, we did stratified analyses by gender and transmission mode. Despite these challenges, our analysis is based on a large sample of people diagnosed with HIV across 31 countries and over 12 years, which strengthens the reliability of our findings. Our study provides a broad overview of the epidemiology of new HIV diagnoses among older adults in the EU/EEA. Increasing new HIV diagnoses among older adults point towards the compelling need to heighten awareness among health-care providers and deliver more targeted prevention interventions for this age group and the total adult population. Contributors LT developed the project idea and drafted the Article. JGD and AP did the epidemiological analysis, and AP helped to draft the Article. All authors developed the epidemiological analysis protocol, contributed to review of the Article, and approved the final version. Declaration of interests We declare no competing interests. Acknowledgments We would like to acknowledge the European Centre for Disease Prevention and Control Library for doing the literature search and Judit Takacs and Andrew Amato-Gauci for their input on drafts of the Article. The EU/EEA HIV Surveillance Network Daniela Schmid (Austria); André Sasse, Dominique Van Beckhoven (Belgium); Tonka Varleva (Bulgaria); Tatjana Nemeth Blazic (Croatia); Linos Hadjihannas, Maria Koliou (Cyprus); Marek Maly (Czech Republic); Susan Cowan (Denmark); Kristi Rüütel (Estonia); Kirsi Liitsola, Mika Salminen (Finland); Françoise Cazein, Josiane Pillonel, Florence Lot (France); Barbara Gunsenheimer-Bartmeyer (Germany); Georgios Nikolopoulos, Dimitra Paraskeva (Greece); Maria Dudas (Hungary); Haraldur Briem, Gudrun Sigmundsdottir (Iceland); Derval Igoe, Kate O’Donnell, Darina O’Flanagan (Ireland); Barbara Suligoi (Italy); Šarlote Konova (Latvia); Sabine Erne (Liechtenstein); Irma Čaplinskienė (Lithuania); Aurélie Fischer (Luxembourg); Jackie Maistre Melillo, Tanya Melillo (Malta); Eline Op de Coul (Netherlands); Hans Blystad (Norway); Magdalena Rosińska (Poland); Isabel Aldir, Helena Cortes Martins (Portugal); Mariana Mardarescu (Romania); Peter Truska (Slovakia); Irena Klavs (Slovenia); Asunción Díaz (Spain); Maria Axelsson (Sweden); Valerie Delpech (UK). References 1 UN, Department of Economic and Social Affairs, Population Division. World population ageing 2013. ST/ESA/SER.A/348. New York, NY: United Nations, 2013. 2 Mahy M, Autenrieth CS, Stanecki K, Wynd S. Increasing trends in HIV prevalence among people aged 50 years and older: evidence from estimates and survey data. AIDS 2014; 28 (suppl 4): S453–59. 3 Prince MJ, Wu F, Guo Y, et al. The burden of disease in older people and implications for health policy and practice. Lancet 2015; 385: 549–62.
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UNAIDS. HIV and aging—a special supplement to the UNAIDS report on the global AIDS epidemic 2013. Geneva: Joint United Nations Programme on HIV/AIDS, 2013. Lazarus JV, Nielsen KK. HIV and people over 50 years old in Europe. HIV Med 2010; 11: 479–81. Smith RD, Delpech VC, Brown AE, Rice BD. HIV transmission and high rates of late diagnoses among adults aged 50 years and over. AIDS 2010; 24: 2109–15. Camoni L, Regine V, Raimondo M, Salfa MC, Boros S, Suligoi B. The continued ageing of people with AIDS in Italy: recent trend from the national AIDS Registry. Ann Ist Super Sanita 2014; 50: 291–97. Pharris A, Quinten C, Tavoschi L, Spiteri G, Amato-Gauci AJ. Trends in HIV surveillance data in the EU/EEA, 2005 to 2014: new HIV diagnoses still increasing in men who have sex with men. Euro Surveill 2015; 20: 47. European Centre for Disease Prevention and Control, WHO Regional Office for Europe. HIV/AIDS surveillance in Europe 2015. Stockholm: European Centre for Disease Prevention and Control, 2016. Wilson KD, Dray-Spira R, Aubrière C, Hamelin C, Spire B, Lert F. Frequency and correlates of late presentation for HIV infection in France: Older adults are a risk group-results from the ANRS-VESPA2 study, France. AIDS Care 2014; 26 (suppl 1): 83–93. Davis DHJ, Smith R, Brown A, Rice B, Yin Z, Delpech V. Early diagnosis and treatment of HIV infection: magnitude of benefit on short-term mortality is greatest in older adults. Age Ageing 2013; 42: 520–26. Davis T, Teaster PB, Thornton A, Watkins JF, Alexander L, Zanjani F. Primary care providers’ HIV prevention practices among older adults. J Applied Gerontol 2016; 35: 1325–42. Ellman TM, Sexton ME, Warshafsky D, Sobieszczyk ME, Morrison EAB. A forgotten population: Older adults with newly diagnosed HIV. AIDS Patient Care STDs 2014; 28: 530–36. Antinori A, Coenen T, Costagiola D, et al. Late presentation of HIV infection: a consensus definition. HIV Med 2011; 12: 61–64. Antoniou T, Zagorski B, Bayoumi AM, et al. Trends in HIV prevalence, new diagnoses and mortality in Ontario, 1996 to 2009: a population-based study. Open Med 2013; 7: e98–e106. Lazarus JV, Laut KG, Safreed-Harmon K, et al. Disparities in HIV clinic care across Europe: findings from the EuroSIDA clinic survey. BMC Infect Dis 2016; 16: 335. Reuter S, Oette M, Kaiser R, et al. Risk factors associated with older age in treatment-naive HIV-positive patients. Intervirology 2012; 55: 147–53.
18 Orchi N, Balzano R, Scognamiglio P, et al. Ageing with HIV: newly diagnosed older adults in Italy. AIDS Care 2008; 20: 419–25. 19 Metallidis S, Tsachouridou O, Skoura L, et al. Older HIV-infected patients—an underestimated population in northern Greece: epidemiology, risk of disease progression and death. Int J Infect Dis 2013; 17: e883–91. 20 Youmans E, Tripathi A, Gibson JJ, Stephens T, Duffus WA. Demographic characteristics and behavioral risk factors of HIV infection and association with survival among individuals 50 years or older. Southern Med J 2011; 104: 669–75. 21 Shah B, Freiman H, Barnette A, Gaye-Bullard N, Hankin A. Characteristics of older adults newly diagnosed with HIV via routine HIV screening in an urban emergency department. Academic Emerg Med 2015; 22 (suppl): S294. 22 Schouten M, Van Velde AJ, Snijdewind IJM, Verbon A, Rijnders BJA, Van Der Ende ME. Late diagnosis of HIV positive patients in Rotterdam, the Netherlands: risk factors and missed opportunities. Ned Tijdschr Geneeskd 2013; 157: A5731 (in Dutch). 23 Tavoschi L, Pharris A, Gomes J, Aj A-G. PE21/12-HIV infection among persons aged 50 years and over in the EU, 2004–2013: missed opportunities for earlier diagnosis? 15th European AIDS Conference; Barcelona, Spain; Oct 21–24, 2015. Abstract PE 21/12. 24 Adekeye OA, Heiman HJ, Onyeabor OS, Hyacinth HI. The new invincibles: HIV screening among older adults in the US. PLoS One 2012; 7: e43618. 25 Tillman JL, Mark HD. HIV and STI testing in older adults: an integrative review. J Clin Nurs 2015; 24: 2074–95. 26 Prati G, Mazzoni D, Zani B. Psychosocial predictors and HIV-related behaviors of old adults versus late middle-aged and younger adults. J Aging Health 2015; 27: 123–39. 27 Vas A, Whitfield C, Cousins D, Papoutsos C, Lee V. New kids on the block—HIV diagnosis among adults aged 50 years and over. HIV Med 2011; 12: 71. 28 Bulajic R, Caprio TV. Risky sexual behavior in the nursing home: balancing resident autonomy and risks. J Am Geriatr Soc 2010; 58: S199. 29 Lazarus JV, Hoekstra M, Raben D, Delpech V, Coenen T, Lundgren JD. The case for indicator condition-guided HIV screening. HIV Med 2013; 14: 445–48. 30 Agustí C, Montoliu A, Mascort J, et al. Missed opportunities for HIV testing of patients diagnosed with an indicator condition in primary care in Catalonia, Spain. Sex Transm Infect 2016; 92: 387–92.
www.thelancet.com/hiv Published online September 26, 2017 http://dx.doi.org/10.1016/S2352-3018(17)30155-8
Comment
HIV diagnosis increasing in older adults in Europe In The Lancet HIV, Lara Tavoschi and colleagues1 report on the growing number of adults aged 50 years or older (ie, older people) becoming infected with HIV in the European Economic Area. The authors used data from the European Surveillance System to find new HIV diagnoses for older and younger (aged 15–49 years) people and compared the two age groups over the period Jan 1, 2004, to Dec 31, 2015. There were 54 102 new diagnoses in older people during that period, corresponding to a rate of new diagnoses of 2·6 per 100 000 population. Although the rate in older people is less than a quarter of that in the younger age group, it is important to remember that these are new diagnoses. The mode of transmission among older adults was predominantly heterosexual, with more men than women becoming HIV positive in older age. Of note, more older people than younger people had CD4 cell counts of less than 350 cells per μL at diagnosis. Many older people are sexually active2 and their sexual health and behaviour affect HIV transmission. Yet older adults have been largely neglected by the prevention community, partly because of an absence of data about their sexual behaviour and the focus on people younger than 50 years. Older adults are often ignored in sexual health policy,3 and have often been omitted from data collection for HIV incidence and prevalence. UNAIDS changed from reporting data only for 15–49-year-olds to reporting data for everyone older than 15 years only in 2006.4 However, data for those aged 50 years or older remained few. UNAIDS subsequently released a special report5 about HIV and ageing in 2013, and its “Gap Report”,6 which was published in 2014, included older adults as a group left behind in both prevention and treatment efforts. Although the focus on younger age groups reflects a very valid concern with rates of infection in younger people,7–9 data collection in people younger than 50 years only suggests a belief that HIV is an infection acquired by younger people and an infection that people age with, rather than one that people acquire in older age. Therefore, Tavoschi and colleagues’ Article is timely in highlighting that increasing numbers of older people are acquiring HIV in Europe each year. HIV infection has implications for the long-term health and wellbeing of older people, particularly if they present with advanced
infection.10 In Europe, the USA, and Canada, increased mortality among older people living with HIV is often attributed to increased prevalence of illnesses such as cardiovascular disease, and kidney and liver failure, which can worsen HIV disease progression.11 These older people are also at greater risk of infectious diseases, such as tuberculosis.12 Non-governmental bodies, such as the Terrence Higgins Trust,13 are actively highlighting the issues facing older people with HIV, including poverty and isolation as well as health-care needs. Prevention of HIV infection in all age groups is essential if the epidemic is to be stopped, and older age groups should not be omitted. Targeted prevention interventions for older people, such as the Age is Not a Condom campaign, launched in 2015 by the New York non-governmental organisation ACRIA, are essential. There is a need for heightened awareness among health-care workers of the risk of HIV infection in older people. People older than 50 years might not have up-to-date knowledge of the risk of HIV infection or prevention methods, particularly if new sexual encounters follow the death of, or divorce from, a longterm partner. Provision of easy access to testing is a first step in getting people living with HIV on to treatment. Testing also provides much needed data for the incidence and prevalence of HIV infection in older adults. These data are essential to governments and non-governmental bodies to inform tailored prevention and mitigation efforts that address the needs of people aged 50 years or older.
Lancet HIV 2017 Published Online September 26, 2017 http://dx.doi.org/10.1016/ S2352-3018(17)30151-0 See Online/Articles http://dx.doi.org/10.1016/ S2352-3018(17)30155-8
For campaing Age is Not a Condom see http:// ageisnotacondom.org/
Janet Seeley Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Tavistock Place, London WC1H 9SH, UK janet.seeley@lshtm.ac.uk I declare no competing interests. 1
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Tavoschi L, Gomes Dias J, Pharris A, on behalf of the EU/EEA Surveillance Network. New HIV diagnoses among adults aged 50 years or older in 31 European countries, 2004–15: an analysis of surveillance data. Lancet HIV 2017; published online Sept 26. http://dx.doi.org/10.1016/ S2352-3018(17)30155-8. Gott M, Hinchliff S. How important is sex in later life? The views of older people. Social Sci Med 2003; 56: 1617–28. Wellings K, Johnson AM. Framing sexual health research: adopting a broader perspective. Lancet 2013; 382: 1759–62. Negin J, Cumming RG. HIV infection in older adults in sub-Saharan Africa: extrapolating prevalence from existing data. Bull World Health Organ 2010; 88: 847–53. UNAIDS. HIV and aging: a special supplement to the UNAIDS report on the global AIDS epidemic 2013. Geneva: Joint United Nations Programme on HIV/AIDS, 2013.
www.thelancet.com/hiv Published online September 26, 2017 http://dx.doi.org/10.1016/S2352-3018(17)30151-0
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